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Tag Archives: 99204

Is this a 99204?

Posted on by
My provider reported 99204. I only see the HPI as a EPF which would bring this to a 99202.

Can anyone take a stab at this and let me know what you think?

Thanks,

Jo

——————————————————————————————-
Chief Complaint: new patient

HPI: 77 y.o. female who is here to estab care w/ new pcp

Health Maintenance:
AAA screen: NEVER
DEXA: NEVER
Mammogram: > 10 YRS
Colorectal ca screen: NEVER
FOBT: DOES EVERY YEAR- NEGATIVE
Depression screen: TODAY
Optho exam: A LITTLE OVER 1 YR
Hep B screen: UNK
Hep C screen: UNK
Flu vaccine: 10/18
Pneumococcal vaccine: NEVER
Zoster vaccine: NEVER
TDap: 2014

Review of Systems:
Constitutional: Negative for weight loss and fever/chills.
Eyes: Negative for visual blurring, double vision, eye pain, scotomata/blind spot, visual loss, red eye and itchy eye.
Ears/Nose/Mouth/Throat: Negative for hearing loss, tinnitus, dizziness, epistaxis, frequent upper respiratory tract infections, sinus trouble, sore throat, runny nose, bleeding gums, dental problem, sinus pain and hoarseness.
Respiratory: Negative for cough, productive sputum, hemoptysis, shortness of breath, wheezing and dyspnea on exertion.
Cardiovascular: Negative for palpitations, irregular heart beat, chest pain, nocturnal dyspnea, trouble lying flat, lower extremity edema and claudication.
Gastrointestinal: Negative for dysphagia, dyspepsia, odynophagia, hematemesis, abdominal pain, exccessive gas or bloating, bright red blood per rectum, constipation, diarrhea, jaundice, nausea, vomiting, abdominal cramps and loose or frequent bowel movements.
Musculoskeletal: Negative for painful gait, back pain, bone pain, muscle pain , muscular weakness, fatigue, nocturnal cramping, joint pain, joint swelling and varicose veins.
Skin: Negative for rash, pruritis, pain, abscess and mass.
Neurologic: Negative for headaches, syncope, paralysis, numbness or tingling of hands, numbness or tingling of feet, involuntary movements, tremor, muscular weakness and vertigo.
Psychiatric: Negative for depression, anxiety, sleep disturbance, difficulty with memory, nervousness, marital problems, abusive relationship, excessive alcohol consumption and illegal drug usage.
Endocrine: Negative for hot flashes, heat/cold tolerance , polyuria and polydipsia.
Hematologic/Lymphatic: Negative for anemia, bleeding problems, easy bruising, fever, night sweats, chills and swollen nodes.
Immunologic/Allergies: Negative for itching, hives and allergies.

History:
Past Medical/Surgical:
Past medical history: Patient has a past medical history of Hyperlipidemia and Hypertension.
Past surgical history: Patient has a past surgical history that includes Cholecystotomy.

Family:
Family history: Patient family history includes Breast Cancer in her daughter; Hypertension in her mother; Ovarian Cancer in her sister.

Social:
Social history: reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol or use drugs. Her sexual activity history is not on file.

History
Drug Use No

History
Sexual Activity
• Sexual activity: Not on file

Social History

Occupational History
• Not on file.

Fish Oil-Omega-3 Fatty Acids 300-1,000 mg capsule
hydroCHLOROthiazide (HYDRODIURIL) 25 mg tablet
lovastatin (MEVACOR) 20 mg tablet

No current facility-administered medications for this visit.

Allergies:
Allergies: She has No Known Allergies.

Physical Exam:

BP 134/73 | Pulse 97 | Temp 97 °F (36.1 °C) (Tympanic) | Resp 14 | Ht 5′ 5" (1.651 m) | Wt 66.2 kg (146 lb) | SpO2 97% | BMI 24.30 kg/m²

Body mass index is 24.30 kg/(m^2).

Constitutional: no acute distress and well developed/well nourished
Eyes: extra-ocular muscle intact (EOMI) bilaterally, lids/conjunctiva normal bilaterally and anicteric bilaterally

Ears/Nose/Mouth/Throat: oropharynx pink and moist, tympanic membranes intact bilaterally and sinuses nontender

Cardiovascular: nondisplaced place of maximal impulse (PMI), normal s1, s2 , regular rhythm, no murmurs, no rubs and no gallops

Respiratory: clear to auscultation bilaterally, normal chest expansion & respiratory effort, no rales, no wheezing and no accessory muscle use

Back: no deformity and no costo-vertebral tenderness (CVAT)

Gastrointestinal: normal bowel sounds, no hepatosplenomegaly, non-tender and no masses

Musculoskeletal: normal gait, no clubbing, cyanosis and full range of motion of joints: all 4 extremities.

Extremity: no peripheral edema and no swelling/erythema/tenderness

Neuro: alert, awake & oriented times three (AA&O x 3), normal light touch sensation and normal strength

Vascular: No venous stasis changes or ulcers

Lymphatic: no cervical nodes, no axillary nodes , no inguinal nodes, no auricular nodes and no epitrochlear nodes

Psych: normal judgment and insight, normal mood/affect and non-anxious

Skin: no rash, warm and dry

Labs/Imaging:

Assessment/plan:

77 y.o. female here for check up and f/u on HTN and HLD

1. HTN-
– ct pres meds
– BP controlled
2. HLD-
– ct pres meds
– obtain recent blood work results
3. Health Care Maintenance
– check routine labs
– Age appropriate cancer screening: refer for mammo and colonoscopy, rec complete skin exam,
– Bone density screening- recommend Vitamin D 1000 units per day, refer for DEXA
– Optho- recommend annual optho exam
– Podiatry- recommend annual pod exam
– Diet- choose foods low in saturated fats and high in fiber. Fresh food is nutritionally better than most prepared foods. Consume multiple servings of fruits and vegetables every day.
– Exercise- walk briskly (powerwalk) 150 minutes per week (30 minutes a day, 5 days a week)
– Wear seatbelts- anytime you are in a moving vehicle, including the backseat.
– Use helmets- for skiing, snowboarding, in-line skating and biking.
– Safe sex- use condoms to reduce your risk of HIV and STIs, screening for STD’s
– Skin- ABCD’s of skin changes, SPF 15 or greater, avoid prolonged exposure to direct sunlight.
– Oral care: Brush and floss your teeth twice a day.
– Vaccines- Flu- UTD, Tdap- UTD
– PNA vax given, tolerated well, no side effects

Visit Diagnoses and Associated Orders

Hypertension, unspecified type – Primary
ICD-10-CM: I10
ICD-9-CM: 401.9

Postmenopausal
ICD-10-CM: Z78.0
ICD-9-CM: V49.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]

Visit for screening mammogram
ICD-10-CM: Z12.31
ICD-9-CM: V76.12

Screening for osteoporosis
ICD-10-CM: Z13.820
ICD-9-CM: V82.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]

Senile osteoporosis
ICD-10-CM: M81.0
ICD-9-CM: 733.01
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]

Need for prophylactic vaccination against Streptococcus pneumoniae (pneumococcus)
ICD-10-CM: Z23
ICD-9-CM: V03.82
PR PNEUMOCOCCAL VACCINE, 23 VALENT, ADULT [90732 CPT(R)]
pneumococcal 23-val vaccine (PNEUMOVAX) 25 mcg/0.5 mL solution [19753]

Hyperlipidemia, unspecified hyperlipidemia type
ICD-10-CM: E78.5
ICD-9-CM: 272.4

Medical Billing and Coding Forum

Clinical Examples for 99204

Posted on by

Initial office visit for a 13-years-old female with progressive scoliosis. (Orthopaedic Surgery)

Initial office visit for a 34-years-old female with primary infertility for evaluation and counseling. (Obstetrics & Gynecology)

Initial office visit for a 6-years-old male with multiple upper respiratory infections. (Allergy & Immunology)

Initial office visit for a patient with generalized dermatitis of 80 percent of the body surface area. (Dermatology)

Initial office visit for an adolescent who was referred by school counselor because of repeated skipping school. (Psychiatry)

Initial office visit for a 50-years-old machinist with a generalized eruption. (Dermatology)

Initial office visit for a 45-years-old female who has been abstinent form alcohol and benzodiazepines for three months but complains of headaches, insomnia, and anxiety. (Psychiatry)

Initial office visit for a 60-years-old male with recent change in bowel habits, weight loss, and abdominal pain. (Abdominal Surgery/General Surgery)

Initial office visit for a 50-years-old male with in aortic aneurysm who is considering surgery. (General Surgery)

Initial office visit for a 17-years-old female with depression. (Internal Medicine)

Initial office visit of a 40-years-old with chronic draining ear, imbalance, and probable cholesteatoma. (Otolaryngology/Head & Neck Surgery)

Initial office visit for initial evaluation of a 63-years-old male with chest pain on exertion. (Cardiology/Internal Medicine)

Initial office visit for evaluation of a 70-years-old patient with recent onset of episodic confusion. (Internal Medicine)

Initial office visit for a 7-years-old female with juvenile diabetes mellitus, new to area, past history of hospitalization times three. (Pediatrics)

Initial office visit of a 50-years-old female with progressive solid food dysphagia. (Gastroenterology)

Initial office visit for a 34-years-old patient with primary infertility, including counseling. (Obstetrics & Gynecology)

Initial office visit for evaluation of a 70-years-old female with polyarthralgia. (Rheumatology)

Initial office visit for a patient with papulosquamous eruption involving 60 percent of the cutaneous surface with joint pain, Combination of topical and systemic treatment discussed. (Dermatology)


Coding Ahead

99203 vs 99204

Posted on by
I code for urology. Our doctors see patients who have not been circumcised yet. So when they see these patients as a new patient and they document a comprehensive HPI, exam, and its a new problem and they prescribe a medication (Betamethasone cream) for the patient, is this considered a 99204? I feel this isn’t a severe enough problem for that. What are your thoughts?

Medical Billing and Coding Forum

Denial for 99204 New vs Established

Posted on by
We have received a denial for E/M code 99204 from a managed care plan stating that the patient was an established patient based on a Diagnostic Assessment 90791, 90785 we did about 10 days prior to the E/M.

My provider wants me to appeal based on the clip from the CMS guide to billing E/M: New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years.

We are a mental health organization and he states that since our providers are not "physicians" then they cannot use the diagnostic assessment as a previously professional services. I have argued that the diagnostic assessment was an encounter and therefore makes this patient established. How can I appeal something that I think is incorrect.

Am I wrong in this matter and should I still appeal?

Medical Billing and Coding Forum

Why selected 99204 as E/M code. Any breakdown if anyone can help

Posted on by
HISTORY: The patient is a female referred by Dr. Thomas for a nonhealing left great toe wound. She is being taken care of at the Care Center with frequent hyperbaric therapies with no significant change in the wound. She denies diabetes.

Past medical history is complicated for multiple past surgeries including a left femoral-to-popliteal bypass graft performed in approximately 20XX at the University of Utah. She had undergone a cadaveric graft following a vein bypass, which she thinks has failed. On the right thereafter, she underwent a successful femoral-to-distal bypass graft, which is doing well. In 20XX, she underwent a right common iliac artery stent placement as well due Peripheral vascular disease.

PAST MEDICAL HISTORY:
1. Hypertension.
2. Keloids.
3. Peripheral vascular disease.
4. Status post gallbladder surgery.
5. Carpal tunnel surgery.
6. Left carotid endarterectomy.

MEDICATIONS:
1. Blood pressure medication.
2. Pain medication.
3. Coumadin 5 mg every Monday, Wednesday, and Friday, and 2.5 mg on the other days. This has recently been increased due to an INR of 1.8 on XX/09/20XX.
4. Vitamins.

ALLERGIES: SULFA.

SOCIAL HISTORY: She denies alcohol and is a non-smoker .She is married, has five children, and is a nurse.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYMPTOMS: A 14-point review of symptoms is positive for joint pain, back pain, difficulty sleeping. She denies chest pain, shortness of breath, nausea, vomiting, and diarrhea.

PHYSICAL EXAMINATION:
HEIGHT: 5′;4"
WEIGHT: 165 pounds
GENERAL: Very pleasant African-American female in no acute distress.
HEENT: Normocephalic and atraumatic. Extraocular muscles are intact.
LUNGS: Clear to auscultation bilaterally.
CVS: Regular rate and rhythm.
ABDOMEN: Soft, obese, and nontender.
EXTREMITIES: The left foot is wrapped. There is a 1+ common femoral artery pulse with a nonpalpable left common femoral artery pulse.
NEUROLOGIC: Cranial nerves II-XII are grossly intact. Alert and oriented times three.

RADIOLOGIC STUDIES: Formal ultrasound imaging was performed by Dr. Andrews in the office today, which demonstrates a proximal fem-to-popliteal bypass graft. There are slow decreased velocities from the proximal to mid thigh region; however, at the junction of the mid to distal one-third, there is no flow identified in the graft.

MRI of the left foot from IMI dated 0X/08/20XX demonstrates findings consistent with cellulitis involving the great toe. No soft tissue abscess.

IMPRESSION:
A nondiabetic female with a complicated past medical history with bilateral vascular bypass procedures due to PAD performed at the Hospital and now with nonhealing left great toe cellulitis. Occlusion of femoral vascular graft .

PLAN: Given the ultrasound findings in my office today of a patent femoral graft to the mid thigh, which occludes, I will attempt recanalization of this graft, which may require stenting with atherectomy and possible TPA to help improve flow into the distal vessels. We will access the right common femoral artery initially.
The patient is currently on Coumadin and I discussed with Jodi, at Peace Cardiology, that we will discontinue her Coumadin as of today and start her on Lovenox 100 mg subcu once a day starting Saturday through Monday. The patient has been scheduled for Tuesday morning at Bright Memorial Hospital.

All the risks, benefits, complications, and alternative procedures have been thoroughly explained to the patient who is in understanding. I did attempt to contact Dr. Davis; however, he is out of town until Monday. I will discuss my findings with him at that time.

David Kramer, MD
Electronically signed by DAVID KRAMER, MD 1/1/20XX

Q=I am confused here as family history is non-contributory which means no credit to the doctor and Past and Social history was met but for new patient past social and family should be met with each item from all three. As per my understanding History was brief, Exam was comprehensive and PFSH-2 . Anyone can help please?

Medical Billing and Coding Forum